Cancer of the cervix and the womb

In Britain each year around 8,000 women develop cancers of the womb and the meek of the womb). In spite of the amount of publicity they often receive, these are two (airly rare types of tumours – they affect far fewer women than, for example, breast, lung or stomach cancers. Together, cervical and other uterine tumours account for only about 10 per cent of all cancers which occur in women in ihe UK. But the fear that this may develop cancer of the cervix or womb often causes a great deal of unnecessary suffering to some women, who may put ofl consulting a doctor when they have symptoms such as vaginal bleeding. If these cancers are diagnosed and treated promptly enough, they can, however, often be effectively treated and sometimes completely cured. This is especially true of cervical cancer for which there is a very efficient early screening programme in most Western countries.

Where the tumours form

The healthy womb is roughly the shape and size of a small inverted pear, King behind the and in front of the At the lower end of the womb is the a narrow canal connecting the vagina with the main part of the womb. Together they form the Both the womb and the cervix are made of many layers of muscle fibres covered on the inside by a thin lining— the It is the epithelium which is usually the site of cancer of the cervix or womb.

The uterus, like other organs in the body, is made up of millions of tiny cells. These cells are continually dividing to produce new ones to replace those which are worn out. As they multiply, cells from the deeper layers of tissue surrounding the uterus move upwards to replace the cells in the epithelial layer which die and flake oil as they mature. This process of replacement is controlled partly by the balance of hormones such as and in a woman’s blood, and partly by the fact that each cell has a built-in mechanism which regulates how quickly it must divide in order to keep pace with the loss of the cell it is replacing.

If a cell’s control system breaks down, perhaps because of an imbalance of hormones, then that cell can give rise to a whole host of other abnormal cells, all out of control and dividing more rapidly than usual. It is this group of uncontrolled cells, spreading haphazardly in all directions and displacing normal cells, that forms the malignant tumour. As it develops the cancer spreads into adjoining tissue, first into the muscle layer of the uterus and then outside the uterus into the surrounding organs such as the bladder and rectum. If untreated, the tumour may invade nearby lymph glands and eventually cancerous cells may be carried in the- bloodstream from their original site-to more-distant parts of the body such as the lungs or liver, where they may form secondary growths.

Women most at risk

So far no single factor has been identified as causing cancers of the- uterus, but researchers have found a number of circumstances which may contribute to the risk of developing these tumours.

Women most at risk from developing cancer of the womb are- those- in the 45 to 60 age group who have never had children. Over half the women affected by this form of cancer are childless.

Cervical tumours, on the other hand, occur mainly in 35- to 50-year-old women who have had children. About 95 per cent of all women with this form of cancer have had families.

It is very rare for virgins to develop cancer of the cervix, and the risk of doing so seems to be increased if you start having sexual intercourse at a comparatively early age, and also if you have a large number of sexual partners. The reason for this is not clear, but it may be that a long and varied sex life causes a certain amount of inflammation of the cervix, and that this in turn tends to result in the epithelial cells becoming cancerous over a period of years.

Cancer of the cervix seems to be rarer in those women whose partners have been circumcised. Again, the reason is not clear, but it is thought that the foreskin of uncircumcised men may trap viruses or other germs which in some way contribute to the risk of their partners developing cancer.

Women with a very high oestrogen level are at greater risk of developing cancer of the womb. One of the main functions of oestrogen is to make the cells lining the uterus divide more rapidly but in women with normal hormone levels, this effect is balanced by the progestogen in the bloodstream. A few women do, however, have a very high oestrogen level. This may happen if, for example, they have a tumour on one of the ovaries which is abnormally increasing the output of this hormone. The chances of these women developing cancer of the womb is further increased if they are also taking a form ..of contraceptive Pill or HRT drug containing a high proportion of the female hormone oestrogen.

Since a balance of oestrogen and pro-gestogen is found in most types of the contraceptive Pill or HRT drugs, there is virtually no danger that these will cause cancer in healthy women.

Symptoms of cancer of the uterus

The most common svmptom of cancers of the uterus is a discharge from the vagina which may consist of a thin water}’ liquid, sometimes tinged with blood or sometimes amounting to a loss of pure blood. The discharge may have an offensive smell, and is likely to be brought on or increased either by sexual intercourse or vaginal douching.

Bleeding from the vagina, except at times of menstruation, should always be taken seriously, and any woman, particularly if she’s above the age of 35, should consult a doctor at the first sign of any abnormal blood loss. Sudden vaginal bleeding in a woman who is well past the menopause should be investigated without delay by a specialist. Also if a woman going through the menopause experiences an irregular pattern of bleeding, she should consult her doctor as soon as possible.

If the tumour has progressed to the stage where the bladder or rectum have become involved, there may be additional symptoms: passing water may be more frequent or painful, or the patient may suffer from cliarrhoea or discharge from the rectum. Pain is usually only a symptom of advanced cancer so if you experience, for example, a pain in your pelvis during intercourse you should consult your doctor. In most cases, he’ll probably find that it is caused by infection or inflammation rather than by any cancerous cells.

Diagnosing a tumour

The doctor will examine your abdomen externally. He will then perform a gentle internal examination in order to detect any abnormality of the cervix, womb or ovaries. This examination will almost certainly involve taking a smear from the cervix and some fluid from the vagina for a laboratory analysis. You may also need to have some simple blood tests.

If your own doctor cannot find a simple explanation for your symptoms -for example a vaginal infection – or if any of the tests show some abnormality, he will probably arrange for you to see a at a nearby hospital. The gynaecologist may arrange for some more detailed tests to be carried out in hospital over a period of a few days.

If the specialist suspects a problem in the cervix, he will do a .

When cancer of the uterus is suspected, the gynaecologist will arrange for the patient to have a (often referred to as a or a under a general anaesthetic. This involves scraping the lining of the womb to obtain further cells for analysis. It should be remembered that the D and C is a very widely used method of treatment for all kinds of gynaecological problems, and is not used only in diagnosing suspected cancer. It will take a few days for the results of these tests to become available to the patient.

Cone biopsy and a D and C are both very minor operations and most patients are able to go home the following day.

Cervical smear test

Your own doctor can perform this simple test, or you can have it done as part of your regular check-up at a family planning clinic.

Before taking a cervical smear, the doctor will first examine you inter-nally and will then gently pass a speculum (a tubelike instrument) into the vagina so that he can see the cervix. Having inspected the cervix carefully, he will then rub a wooden spatula across the neck of the womb to remove some of the surface cells. These cells are then placed on a microscope slide and sent to a local laboratory for analysis. The whole procedure takes but a few minutes.

The result of the smear will usually take a week or two to come from the laboratory and if it indicates any abnormality, your doctor will get in touch with you. If you are called back, don’t be alarmed as this test can detect many conditions other than cancer, including common vaginal infections such as thrush. One of its major advantages is that by showing the existence ofpre-cancerous cells it can predict the possibility of cancer up to 20 years in advance. At this early stage, a cone biopsy can be performed to remove any abnormal cells which may be present before a tumour develops.

Cone biopsy

This is performed under a general anaesthetic, and involves the removal of a cone-shaped piece of tissue from around the part of the cervix that protrudes into the vagina. In some hospitals, cone biopsy has been replaced by a technique using a laser oeam which is controlled by a periscopelike instrument placed in the vagina. This allows an even smaller amount of tissue to be removed from the edge of the cervical canal.

The tissue is then analyzed. The biopsy may reveal the presence of pre-cancerous cells or the existence of an early tumour. If, however, the cut-away surface of the cone is free from abnormal cells, then there is a very good chance that the biopsy has cured the patient and she will need no further treatment.

This is because in its initial stages cancer of the cervix is confined to one specific area and affects only superficial layers of cervical tissue. It is also a type of cancer which spreads only very slowly and is, therefore, unlikely to have invaded other parts of the body. Once the tumour has been removed, so that the remainder of the cervix is quite clear of abnormal cells, no problems should remain.

Treating cancers of the cervix and womb

If a tumour of the cervix or womb is diagnosed, a number of tests will be done to determine die nature and extent of the cancer to help the specialist decide on the most suitable course of treatment in each case. X-rays of the patient’s kidneys and abdomen will show whether the cancer has spread to these sites.

Treatment of cancers of the cervix and womb may involve surgery, radiotherapy or drugs, or a combination of these. Sometimes there is more than one form of suitable treatment in a particular case, and the specialist concerned will usually discuss the various possibilities with the patient so that she can also be involved with the choice of treatment.

Surgery

Some patients will need an operation to remove the womb or cervix and sometimes other organs, such as the ovaries, if these have also been affected by the tumour. Although much depends on the condition of the individual patient, surgery is usually performed when the tumour is not too far advanced and is confined to a fairly specific area, so that it can be removed completely.

After an operation there will, of course, be an abdominal scar, though its size will vary according to the site and extent of the cancer-often a bikini-line incision is all that is required. Following surgery, the patient will probably have to stay in hospital for a couple of weeks and will then be allowed to go home.

Radiotherapy

Sometimes surgery is preceded or followed by a course of radiotherapy, or this may be given as a treatment on its own. Radiotherapy for cancer of the cervix tuav be given by inserting an containing radioctive material such as radium into the vagina under general anaesthetic, so that the treatment is con-centrated at the site of the tumour. The capsule containing the radioactive substance is left inside the patient and removed at a later date – usually after about three days. For some early stages this may be all that is required, but patients with more advanced tumours which have sometimes spread to other organs may also need external radiotherapy. This is given by a machine similar to that used for taking ordinary X-ray pictures, but which emits far more powerful rays capable of destroying cancer cells.

External radiotherapy usually lasts Irom four to six weeks, during which time the patient lives at home and visits the hospital daily for treatment. During treatment the patient may feel rather tired and may also suffer from some nausea, sickness or diarrhoea. However, once the treatment is finished, these reactions should disappear. Long-term side effects from radiotherapy are extremely rare.

Chemotherapy

Hormones or may be prescribed for some patients, either as a complete treatment on their own or following surgery andor radiotherapy. At certain stages, cancer of the womb is sometimes very responsive to treatment with hormones such as progestogens, which are usually given in tablet form.

After all these treatments, a cancer patient should be able to continue a perfectly satisfactory sex life, although if the ovaries have been removed some hormonal treatment, such as die insertion of oestrogen cream, may be needed to keep the lining of the vagina healthy. Radiotherapy may cause the vagina to thicken and contract some months after the treatment. Again, die application of oestrogen cream can help, but the best way to stop this happening is to have regular intercourse. This helps to stretch the tissue in and around the vagina and so prevents any long-term damage from developing. For this reason many doctors recommend that gentle love-making should begin as soon as the immediate effects of any treatment have worn off, to keep the vaginal tissues clastic.

Preventing cancer of the uterus

Apart from the impractical and unattractive solution of having the whole womb and cervix removed at an carly age, there is no foolproof method of avoiding cancers of the uterus. The risks can, however, be reduced by sensible behaviour.

If you do have frequent changes of sexual partner, use a barrier contraceptive, such as a cap or sheath, which prevents any potential cancer-causing viruses from entering the cervix, if your husband or regular lover is not circumcised, encourage him to make sure that the head of the penis beneath the foreskin is kept clean and free from infection by regular washing. Above all, make sure you have a regular cervical smear at least once eveiy three years, especially if you’re over 35, and even if you have recently had a normal smear do not ignore symptoms such as unusual vaginal bleeding — consult vour doctor as soon as possible.